A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?
extend one leg and allow the client to slide down the leg to the floor.
move both feet together when the client begins to fall
wrap both arms around the client's arm and shoulders
protect the client's extremities while lowering them to the floor.
The Correct Answer is A
A. Extend one leg and allow the client to slide down the leg to the floor.
It helps to control the fall, protects the client from injury, and allows the nurse to safely guide the client to the floor without using excessive force.
B. Move both feet together when the client begins to fall.
Keeping the feet together reduces stability and increases the risk of both the client and nurse falling.
C. Wrap both arms around the client's arm and shoulders.
This could cause injury to the client’s upper body and doesn't provide support for a safe fall.
D. Protect the client's extremities while lowering them to the floor.
While protecting extremities is important, the nurse’s primary action should be to use proper body mechanics (like extending one leg) to safely lower the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Extend one leg and allow the client to slide down the leg to the floor.
It helps to control the fall, protects the client from injury, and allows the nurse to safely guide the client to the floor without using excessive force.
B. Move both feet together when the client begins to fall.
Keeping the feet together reduces stability and increases the risk of both the client and nurse falling.
C. Wrap both arms around the client's arm and shoulders.
This could cause injury to the client’s upper body and doesn't provide support for a safe fall.
D. Protect the client's extremities while lowering them to the floor.
While protecting extremities is important, the nurse’s primary action should be to use proper body mechanics (like extending one leg) to safely lower the client.
Correct Answer is D
Explanation
A. Log rolling every 2 hr
Log rolling is appropriate for spinal precautions, not necessary in Buck’s traction.
B. Passive range-of-motion exercises of the right leg
The leg in traction must remain immobilized; no ROM exercises on the affected leg.
C. Active range-of-motion exercises of the left leg
While this can help prevent deconditioning, it’s not as effective for overall mobility as isometric exercises.
D. Isometric exercises of both legs
Isometric exercises (e.g., quad or glute squeezes) promote circulation and prevent muscle atrophy in both limbs without disturbing traction.
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